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I <br />SAN JOAQUIebUNTY ENVIRONMENTAL HEALTH*ARTMENT <br />SERVICE REQUEST <br />Type of Business or Property <br />c�As SrATILO cel <br />FACILITY ID # <br />b3 <br />SERVICE REQUEST # <br />OWNER / OPERATOR <br />Jp ,p R a CHECK If BILLING ADDRESS <br />V` �j ` V `W <br />� <br />FACILITY NAME �/' <br />1tYLC 13W& S vte LL Kcct_ c Vc+4,* <br />SITE ADDRESS ?� S <br />Street Number <br />N <br />I Direction <br />& <br />Street Name <br />--r")x� <br />Cit <br />Zi Code <br />HOME or MAILING ADDRESS (If Different from Site Address) <br />Street Number <br />Street Name <br />CITY STATE ZIP <br />PHONE #1 EXT. <br />APN # <br />LAND USE APPLICATION # <br />PHONE #2 EXT. <br />BOS DISTRICT <br />LOCATION CODE <br />CONTRACTOR / SERVICE REQUESTOR <br />REQUESTOR <br />L-[([ Pl Ar e e7 i (K5 a TZ <br />CHECK If BILLING ADDRESS <br />BUSINESS NAMElJ�) <br />S�try �C� SE-c>LtLot;� S s'E-euu� ,� C . <br />PHONE <br />(1443--�c>3 <br />EXT, <br />HOME or MAILING ADDRESS <br />FAx# <br />CITY &(,t Jot <br />STATE (' <br />zip Q �_l01 <br />BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br />acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br />or activity will be billed to me or my business as identified on this form. <br />also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br />COUNTY Ordinance Codes, Slandards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: e--t-L.i:a e ( L c Ir d DATE: <br />PROPLI411 / BUSINESS OWNER ❑ OPERATOR / MANAGER ❑ OTHrR At I TIIOil IzrDAcrNr � i'cti>�Ulc�t,L�� c��ceer <br />IIAPPL1C.1NT iS 1701 the BILLING PARTY, progf of authorization to sign is required Title <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the <br />above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br />information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br />provided to me or my representative. 1` <br />TYPE OF SERVICE REQUESTED: li �' ( (A_-5 <br />L-[([ Pl Ar e e7 i (K5 a TZ <br />�\I <br />COMMENTS: <br />c00N� <br />JC POv�N SNS PL <br />oA\J PPaGMENS <br />pE <br />\A'r— <br />ACCEPTED BY: <br />EMPLOYEE #: <br />DATE: <br />ASSIGNED TO: <br />EMPLOYEE #: <br />DATE: <br />Date Service Completed (if already comple <br />d): <br />SERVICE CODE: <br />P I E: <br />Fee Amount: G Q <br />Amount Paid , Ov <br />Payment Date <br />Z1 d <br />Payment Type <br />Invoice # <br />Check # <br />s <br />Received By: <br />EHD 48-02-025 SR FORM (Golden Rod) <br />REVISED 11/17/2003 <br />